Ethics committees and countries in transition: a figleaf for structura
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《英国医生杂志》
1 Imperial College London, London W6 8RP r.ashcroft@imperial.ac.uk
Boroveki and colleagues argue that hospitals are ethical institutions, and that the norms they embody are subject to pressure and change as the institutions and their contexts change.1 They discuss how bioethics as an explicit way of discussing ethical norms and moral dilemmas has increasingly been institutionalised within Croatian hospitals, and analyse some of the defects of this process to date. In particular they identify three main features of hospital ethics committees which undermine their effectiveness: a continuing tradition of paternalism within medical practice; the bureaucratic, top-down implementation of ethics committees within the Croatian healthcare system; and the confusion of roles between hospital ethics committees and research ethics committees.
Some of their findings bear further analysis: for instance, it is not clear what is "average" in terms of the ethical knowledge of ethics committee members, either in absolute terms (what is the ideal for what they ought to know?) or in relative terms (average compared with whom?). These issues remain open questions in most of the countries in which ethics committees and ethics consultation have been implemented for much longer.2 3 Yet the issues presented in this article resonate across European health systems, despite considerable variation in the implementation of and rationale for ethical decisions in clinical practice.
Given the nature of health systems reform and socioeconomic transition in eastern Europe, what problems is clinical ethics supposed to address, and why should it be a solution to them? Many health systems in Europe are under considerable strain: problems of inadequate resources, high direct costs for patients, inequalities in access, corruption, and formal or informal rationing are as real as the "traditional" clinical ethics issues concerning decision making at the end of life or resolution of conflicts between family members and staff. In addition, as clinical research increasingly migrates to health systems, imposing lower costs on sponsors or researchers, hospitals have strong incentives to take on research projects that may not be in the best interests of the patients or the institution as a whole. Yet it is far from clear that the resources of clinical ethics are particularly apt for addressing these kinds of problems of structural adjustment or professional "deformation."4 The language of ethics risks being used to ratify decisions made for reasons of pragmatism or expediency. Institutions may find it more useful to set up ethics committees more to satisfy foreign partners' or research sponsors' requirements, rather than to address problems of concern to patients.
Ethics committees can serve many useful functions: education, dispute resolution, regulation, policy development. To be genuinely useful to clinicians and patients, and to be morally legitimate, ethics committees need to have both a clear sense of purpose and a clear sense of how best to achieve that purpose. Medical ethics scholars must take up the challenge of addressing the moral problems of social transition, otherwise they will be merely a moral figleaf covering the structural violence in countries in transition.5
Competing interests: None declared.
References
Boroveki A, ten Have H, Orekovi S. Ethics and the structures of health care in the European countries in transition: hospital ethics committees in Croatia. BMJ 2005:331: 227-9.
Slowther A, Johnstone C, Goodall J, Hope T. Development of clinical ethics committees. BMJ 2004;328: 950-2.
Royal College of Physicians. Ethics in practice. London: Royal College of Physicians, 2005.
Dwyer J. Teaching global bioethics. Bioethics 2003;17: 432-46.
Farmer P. Pathologies of power: health, human rights, and the new war on the poor. Berkeley: University of California Press, 2005.(Richard E Ashcroft, reader1)
Boroveki and colleagues argue that hospitals are ethical institutions, and that the norms they embody are subject to pressure and change as the institutions and their contexts change.1 They discuss how bioethics as an explicit way of discussing ethical norms and moral dilemmas has increasingly been institutionalised within Croatian hospitals, and analyse some of the defects of this process to date. In particular they identify three main features of hospital ethics committees which undermine their effectiveness: a continuing tradition of paternalism within medical practice; the bureaucratic, top-down implementation of ethics committees within the Croatian healthcare system; and the confusion of roles between hospital ethics committees and research ethics committees.
Some of their findings bear further analysis: for instance, it is not clear what is "average" in terms of the ethical knowledge of ethics committee members, either in absolute terms (what is the ideal for what they ought to know?) or in relative terms (average compared with whom?). These issues remain open questions in most of the countries in which ethics committees and ethics consultation have been implemented for much longer.2 3 Yet the issues presented in this article resonate across European health systems, despite considerable variation in the implementation of and rationale for ethical decisions in clinical practice.
Given the nature of health systems reform and socioeconomic transition in eastern Europe, what problems is clinical ethics supposed to address, and why should it be a solution to them? Many health systems in Europe are under considerable strain: problems of inadequate resources, high direct costs for patients, inequalities in access, corruption, and formal or informal rationing are as real as the "traditional" clinical ethics issues concerning decision making at the end of life or resolution of conflicts between family members and staff. In addition, as clinical research increasingly migrates to health systems, imposing lower costs on sponsors or researchers, hospitals have strong incentives to take on research projects that may not be in the best interests of the patients or the institution as a whole. Yet it is far from clear that the resources of clinical ethics are particularly apt for addressing these kinds of problems of structural adjustment or professional "deformation."4 The language of ethics risks being used to ratify decisions made for reasons of pragmatism or expediency. Institutions may find it more useful to set up ethics committees more to satisfy foreign partners' or research sponsors' requirements, rather than to address problems of concern to patients.
Ethics committees can serve many useful functions: education, dispute resolution, regulation, policy development. To be genuinely useful to clinicians and patients, and to be morally legitimate, ethics committees need to have both a clear sense of purpose and a clear sense of how best to achieve that purpose. Medical ethics scholars must take up the challenge of addressing the moral problems of social transition, otherwise they will be merely a moral figleaf covering the structural violence in countries in transition.5
Competing interests: None declared.
References
Boroveki A, ten Have H, Orekovi S. Ethics and the structures of health care in the European countries in transition: hospital ethics committees in Croatia. BMJ 2005:331: 227-9.
Slowther A, Johnstone C, Goodall J, Hope T. Development of clinical ethics committees. BMJ 2004;328: 950-2.
Royal College of Physicians. Ethics in practice. London: Royal College of Physicians, 2005.
Dwyer J. Teaching global bioethics. Bioethics 2003;17: 432-46.
Farmer P. Pathologies of power: health, human rights, and the new war on the poor. Berkeley: University of California Press, 2005.(Richard E Ashcroft, reader1)